Tool 9: Transitional Care Planning



Tool 9: Whole-Person Transitional Care Planning ToolPurposeThe social, economic, and geographic conditions in which individuals live have a profound impact on individuals’ health status. Efforts to reduce readmissions by optimizing self-management or long-term health status will predictably fail for individuals whose pressing fundamental survival needs are not met. Prompt recognition of complex nonclinical (“social” needs), such as housing, transportation, and social support, can greatly affect the likelihood that those needs can be addressed, rather than deferred, prior to discharge. This task will often require going well beyond the brief “social history” that is contained in the physician’s admission history and physical.Furthermore, reliable identification of these needs is necessary but not sufficient to reduce readmissions. The ‘active arm” of efforts to reduce readmissions is in ensuring a successful linkage to the anticipated range of care and support services after discharge. The easier it is to “see a problem, fix a problem,” the easier it will be for your hospital staff to execute a safe, effective transition reliably for your patients.DescriptionThis tool provides discharge planners with a set of prompts to identify readmission risks and to take steps to ensure those risks are addressed in the transitional care (discharge) plan. StaffDay-to-day readmission reduction champion to test, adapt, and incorporate into existing workflow with frontline staff. Time RequiredIncorporate into regular discharge planning assessment and referrals.Additional ResourcesSee Section 4 of the Hospital Guide to Reducing Medicaid Readmissions for more information on implementing a reliable, whole-person transitional care process, and Tool 11: Community Resource Guide for community resource information that can be used to populate the right side of the Whole-Person Transitional Care Planning Tool.Tool 9: Whole-Person Transitional Care Planning ToolReadmissions rarely result from a singular breakdown in the transition of care and posthospital supports. A team at Kaiser Permanente in Northern California reviewed more than 500 adult readmissions (all payer, all ages) from across 18 of their hospitals. Among 250 readmissions they deemed to be potentially avoidable, an average of 9 factors contributed to each readmission.The message from this person-centered view of readmissions is that no single issue defines readmission risk. Take a “whole-person” view of transitional care and ongoing care needs to better identify not only risk of readmission, but also transitional care services and supports needed to address those needs so you can minimize readmission risk. As is evident by the many domains on this assessment form, it can be a valuable tool for not only hospital discharge planners, but also for “receiving” providers and agencies in postacute and community-based settings. Best practice is to share this assessment with “receiving” providers in the community. As your cross-continuum team gains experience with whole-person, cross-setting assessment, you may be able to gain efficiencies when patients return to the hospital and this comprehensive view of their needs has already been completed and is shared with the inpatient team from the outpatient setting.Whole-Person Care Transitional Planning ToolReadmission Risks and/or Posthospital NeedsUncover patient’s nonclinical issues and challenges in accessing posthospital care to prevent avoidable hospitalizations in the future. Access to Ambulatory CareNo regular source of careDifficulty with transportation to medical careWork/family responsibilities that pose barrier to appointmentsRegular use of emergency room for careAccess to Behavioral Health CareHistory of receiving behavioral health servicesConcern about emotional or mental healthAlcohol or drugs affecting health and wellnessNeeds linkage to behavioral health services Functional StatusFunctional limitationsCognitive limitations, including executive functionLow self-activation or self-efficacyDisabled, may qualify for Aging and Disability Resource Center or other servicesUnstable/Inadequate HousingLack of stable housingLack of heat or coolingEnvironmental hazards affecting health (mold, etc.)Lack of safety and security within or outside the homeFinancial InsecurityDifficulty paying for basic survival needs (shelter, food)Difficulty paying medical-related costs (copays, supplies)Must prioritize survival versus medical needsFood Insecurity/accessLacks access to adequate amounts of foodLacks access to nutritious or medically appropriate dietSocial Connection/IsolationLives aloneLacks friends/family/connections Legal IssuesBarriers due to insurance coverage, utilities, pending evictionRecent or repeated incarceration or detentionLanguage or Literacy IssuesLow literacy, low numeracyLow health literacy—diagnoses, medications, care planLow or no ability to speak EnglishActions to Take Prior to DischargeUse the improvement motto, “See a problem, fix a problem.” This list represents possible interventions you may identify for a patient. Modify it to meet the most common needs for your patient population.Interdisciplinary Care Planning and CoordinationObtain high-risk readmission team consultContact an MCO, ACO, PCMH, health home care manager, as applicableContact community clinical, behavioral, and social service providersObtain pharmacist consult Obtain social work consultObtain pain management or palliative care consult, as applicableObtain psychiatry consult, as applicableDevelop individualized transitional care planShare plan with ED, outpatient providers, community service providersProvide ServicesIdentify whether eligible for (Medicaid) health home and contact health home to initiate screening and enrollment processContact MCO, ACO, PCMH, health home medical director if high-risk patient is not currently in care management to advocate for enhanced servicesArrange for bedside delivery of medications Discuss cost of medications, how patient will obtain them; modify as neededDiscuss transportation and arrange as neededOffer to provide transitional care followup services (if available)Arrange for Next Steps Ensure all patients have a primary care provider or temporary provider (“bridge” clinic)Schedule followup with primary care providerSchedule followup with relevant specialistsSchedule followup with behavioral health providerInitiate initial eligibility screen for services (health home, adult day, etc.) or allow social/support service entity to screen patient prior to dischargeAsk for best contact number for purposes of postdischarge followup callLink to PostHospital Supports and ServicesLink to transitional care navigating and support services for 30 daysLink to community behavioral health servicesLink to community health worker or navigator programsLink to housing with services agencyLink to food programLink to county health department provided servicesLink to community/faith-based or volunteer servicesLink to Medical-Legal PartnershipLink to adult day health servicesLink to language-concordant navigation or advocacy services ................
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